Insurance coverage after Mexico surgery

kellyk · May 9, 2005

(I am cross-posting this in the Insurance Forum too. Wanting to maximize viewing by members because I am so perplexed and need to hear from others ASAP.)

I am scheduled to have surgery with Dr. Ortiz on May 18. I made one more phone call to my insurance company (PHP of Mid-Michigan) to verify that follow up treatment would be covered. Unfortunately, my call only raised more questions and concerns for me.

I had called some time ago and had been assured that any "complications" from the surgery would be covered. Today I was told that if I presented with vomiting or internal bleeding, as complications from the surgery, those would be covered. But, if I required any "follow-up" procedures dealing specifically with the band, including its removal, those procedures would "not likely" be covered.

I think in order for me to go forward with the band in Mexico, I have to assume the worse case scenario -- no coverage for any follow-up procedures. I am just wondering how big a gamble I am taking if I go forward.

Anyone with any insight? Those of you who were operated on in Mexico, have you had any subsequent insurance problems? Please let me hear of any. I was so determined to have this surgery but now I am thinking that I shouldn't if I will not have any insurance coverage. While I have drummed up the $9500 to have the band implanted, I don't have excess funds to deal with more surgeries in Mexico. Help!

hagerteresa · May 9, 2005

The vast majority of people don't need any follow up procedures. I checked with my insurance too before going and they assured me they would cover ANY complications. They won't cover my fills but I can submit them to my flex and they will get reimbursed. I think insurances have to cover you in the event of any emergency but hopefully others with more experience can post too. Are you close enough to Mexico to get your fills there or have you found a local fill doctor? That is an absolute must before you go! Line up your fill doc now! Anyway best wishes, Teresa

Alexandra · May 9, 2005

Hi Kelly,

I think your best source of definitive information would be your state's insurance department or department of health (whichever has jurisdiction over HMOs in your state). The state may have laws that override what your carrier says, and in any event I'd never take the word of a customer service rep for the final say on anything.

IN GENERAL, complications down the road should be covered as separate medical events. It doesn't matter what the source of that medical event is--if you had a tattoo that got infected they're not going to deny you the coverage for that. Or if you had a hair-dye accident they couldn't deny you coverage for that. Unless state law specifically allows them to do so, it's unlikely that insurance carriers can exclude treatment for medical conditions brought about by voluntary acts (like banding). But it is possible, so check with your state for the situation where you live. Other people's experiences are going to be no help at all with respect to your situation.

This doesn't address whether fills would be covered by your carrier. If they exclude banding, they'd also most likely exclude fills or routine followup visits.

kellyk · May 10, 2005

Thank you, Hagerteresa for your reassurance. And Alexandra, I will call the insurance department or bureau tomorrow. Thanks for that tip! What you say makes sense to me but it seems like insurance issues never make sense to me. Sure is frustrating! Thanks again.

KarenB · May 10, 2005

From what I've been told, routine aftercare is not covered; but any emergency procedure would be. BTW, I am very happy w/Dr. Ortiz. My daughter is being banded by him on 5/26--we'll miss you by one week! Where do you live??

kellyk · May 10, 2005

Hi, KarenB. I live in the mid-Michigan area. Work in Lansing. Glad to know that you are pleased enough with Dr. Ortiz to send your daughter to him.

As for the fills, I always planned on paying for those out of my own pocket. Did you go back to Ortiz for your fills? I am planning on him doing at least my first fill.

princess_n_thep · May 10, 2005

I would think that if you needed the band removed because of erosion or slippage you would WANT to go back to Dr. Ortiz. Not only would you not be paying for it but he will reband you in 6 months with no charge I believe. He definitely takes care of "his own" and would want to fix you if that happened. He wants you to be a happy bandster.

KarenB · May 11, 2005

Hi Kelly. I went to him for my 1st fill, and I'm seeing Dr. Martinez again on the 26th for a barium swallow since I'll be there with my daughter. The fills I've had here have been o.k., but not as exact as his. Your date is right around the corner! Please let us know how everything is when you can.

Best of luck,

the best me · May 11, 2005

Kellyk, I went to the Emergency Room 1 week after being banded. I was so restricted and PB'd and swelled and was unable to drink adequate fluids and I went in for IV fluids and had X-rays of my band to see if I had ANYthing going through (I did, very little) and it's been a slow recovery. I am still very restricted but eating and doing fine now. Anyhow, my insurance DID pay for my ER visit. If I had made an appointment with my local band doc, they would not have paid (I don't suspect) and it would have been out-of-pocket. So the insurance should pay for emergency complications, should you need it, but I wouldn't expect them to pay for fills, follow-along, office visits to a band doc, the type of thing. Especially if it's not a covered surgery (mine wasn't, I went to MX) Hope that helps and gives you some reassurance.

Do what Alex said and make though calls still, though. She's purdy smart...listen to her.

kellyk · May 11, 2005

Thanks, everyone, for your replies.

I had a phone consult with Dr. Ortiz tonight and I feel very reassured about my decision to have him handle my surgery. He told me that he really insists that any follow up care be conducted by him because he wishes to make sure that I am a success. He said that if there were any subsequent complications with my band, he would see me and not charge me any doctor fee. He said that if I had to have the band removed, the hospital fee is about $3,000. If my port needed to be revised, the fee for the hospital is around $350. He did stress to me that the complication rate for this surgery is very low but not zero.

I was extremely impressed by Dr. Ortiz. He seems extremely dedicated to his patients. He spent a little over 30 minuites on the phone with my friend and me and answered our many, many questions. He is very personable, has a good sense of humor, and seems to be very empathetic to his patients' situation.

One week from today I will be in Mexico. I am excited and nervous although I am not nearly as nervous after speaking to Dr. Ortiz.